Date: Provider: Location:
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Delivery
Duration of Pregnancy (in weeks):
Mode of Delivery:
Date of Delivery:
Blood Loss:
Condition of Mother:
Apgar Score (1 min):
Apgar Score (5 min):
Apgar Score (10 min):
Resuscitation Done:
Place of Delivery:
Delivery Conducted By:
Drugs Administered at Delivery (Mother)
Drug Dose Dose Units Frequency Duration Duration Units